Introduction to the Electronic Medical Record

Introduction to the Electronic Medical Record (EMR) Introduction to the Electronic Medical Record (EMR) Gary L Williams Western Governors University Introduction to the Electronic Medical Record (EMR) The new millennium has produced many changes in the world as we know it. Our national security which seemed to be impermeable has revealed its vulnerability to being breached. Remember September 11, 2001 when the hi-jacking of planes lead to the destruction of the Twin Towers in New York City, and severe damage the Pentagon in Washington DC.

Now our Healthcare System has now moved into the information highway. How you may ask, through the introduction of the EMR. So will the EMR be safe and secure? Let us investigate. So just what is the EMR? There are many formal definitions but the one that stands out and will be used today is from the Healthcare Information and Management Systems Society (HIMSS). It states: The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.

Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting. (HIMSS) Within this definition there is a multitude of system components.

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Think of it like the multiple Introduction to the Electronic Medical Record (EMR) dividers that were found in the paper medical record. For instance, you may see headers like, medication record, order entry, nursing assessments, the plan of care, education, radiology, cardiology, etc. Under the medication tab lays the eMAR, medication history, and reconciliation. Each band with the click of the mouse will open a new file within this record. The design is formatted to follow a systematic flow with check boxes, drop down lists, or free text space to document the patient findings, activities, and assessments.

The EMR will have many benefits for the entire healthcare team and the patient. By development and design with the assistance of key personnel, the EMR should flow and make documentation easier. By having a standardized flow and options to document the standards of care, documenting should become easier and provide more consistency. Take for example a urine description. You may see for color description amber, yellow, red, clear, or tea. Then cloudy, turbid, clots, or mucous followed by malodorous, sweet, or pungent. This will provide a means of potential measurement for Evidence-Based Medicine (EBM).

How many patients with UTI receiving Bactrim DS have amber mucous pungent urine on a GU unit? Can you see the pattern? The EMR will assist in critical thinking as well. Your physical assessment for instance may be by body system or a complete head to toe assessment. These screens will assist the nurse in reminders of required documentation. The nurse may receive a task list for a certain procedure or required documentation of a high risk factor, such as fall precautions, to alert the bedside nurse or technician that the document is due or past due.

Introduction to the Electronic Medical Record (EMR) The EMR will provide real time data and reports from various disciplines within the healthcare facility. For instance, a Vancomycin trough was ordered at 0700 and its 0900 and the IV medication is due. By selecting the laboratory tab your result will be there in front of you before the dose is administered. The same can be expected of radiology imagining results, EKG, stress test reports, a bedside capillary glucose test done by the technician. No more searching through multiple computer systems or piles of lab results to find the data you need.

The information is there and readily available. Healthcare providers have the penmanship of a deranged mad scientist. How often do you have multiple nurses trying to determine what Dr. Hyde just wrote? What if you guess wrong? Now you place that call to Dr. Hyde for clarification when you have a multitude of things to be doing. With Computerized Provider Order Entry (CPOE), no longer will guessing what was written be an issue. Standard order sets will be available with the opportunity to be individualized or modified from a pre-determined list of ommon orders for routine admission or for specific disease processes like the Acute Myocardial Infarction. Included may be diet, activity, vital signs, IV fluids, labs, EKG, PCXR, or consults. As touched upon earlier with the urine sample report, there is a myriad of potential data that can be extrapolated to form reports for research and to assist with the EBM. What is the average number of days for patients on the ventilator for June, 2011? How many patients in the rehabilitation unit have pressure ulcers? Maybe a nurse says to the unit manager that it seems like a large number of the patients on the unit have C- Difficile?

A report can be run to show Introduction to the Electronic Medical Record (EMR) trends of the patients with this condition. Maybe it’s a hand washing issue or cross contamination from multi-use bathroom facilities. There are many opportunities that would at best have been difficult to track from the old paper medical record. Identity theft is rampant in this world of technology. How will the EMR be secured? How can the nurse access the EMR? Today home computers are almost essential. The same virus and malware that affect your home computer can infect the EMR if security is lacking.

The Information Technology team will provide the overall security for the system by continuous upgrades to software like antivirus and firewall protection. Each team member will be issued a unique log-in and password to access the EMR. This must be kept strictly confidential for the nurse’s protection. This secure log-in is like a finger print of the assigned user. When the EMR is accessed, there is a time stamp of what records were accessed, for what length of time, and by whom. A secure trail of entry into the EMR can be traced. What is the Personal Health Record (PHR) and how does it differ from the EMR?

The PHR is essentially the same document that you would produce in the Physician’s Office. The PHR can be completed online either through a Physician’s Office or through an outside resource. Things that would be included in the PHR might be your name, address, telephone number, date of birth, and possibly the social security number. This record could also contain your Physicians name and phone number, the list of your current medications and dosages, a list of current and Introduction to the Electronic Medical Record (EMR) past medical conditions, and passed surgical history.

This type of a record is usually maintained by the patient themselves. The PHR will differ from the Electronic Medical Record in that the Electronic Medical Record is property of the Health Care facility and not the consumer. The personal health record becomes more vulnerable to breaches in security since it is maintained by the consumer. For example, I might give my sign on and password to my family or friend to input data for me. This obviously breaches ones security. This allows access to these individuals to alter ones personal health record at will.

The website that maintains the personal health record may not be as secure as that of the Health Care facility. The Electronic Medical record is usually maintained by the healthcare facility, outpatient clinic, or Physician’s Office. These healthcare facilities must maintain high security to protect the information within that medical record. In 1996, Congress passed a law entitled The Health Insurance Portability & Accountability Act (HIPAA). This law was designed: -To improve portability and continuity of health insurance coverage in the group and individual markets. To combat waste, fraud, and abuse in health insurance and health care delivery. -To reduce costs and the administrative burdens of health care by improving efficiency and effectiveness of the health care system by standardizing the interchange of Introduction to the Electronic Medical Record (EMR) electronic data for specified administrative and financial transactions. -To ensure protecting the privacy of Americans’ personal health records by protecting the security and confidentiality of health care information. (James) The security and confidentiality are paramount. Fines are levied as a result of a breech to the HPPA law.

There must be alerts to vulnerabilities, safeguards to help protect the EMR and the Information Technology team must be able to identify possible threats. Using an EMR (electronic medical record) has no absolute right and wrongs in either computer equipment or software for HIPAA compliance. Usually there are four areas to examine: -Physical Security – can your computers with patient data be stolen? -User Security - can anybody log on to the patient database? -System Security – what happens on a hard drive crash? -Network Security – can unauthorized persons outside your facility access patient data? Milne, 2006) Security is never easy to maintain; it requires continuous safeguarding. As a team we are all responsible to assist in the security of the EMR. Always log on and off when you are no longer Introduction to the Electronic Medical Record (EMR) using the bedside computer. Always check before charting that it is indeed you that is longed into the system and that only one patient record at a time is open for use. The EMR can be a valuable tool for Quality Improvement (QI). Through the design phase, a number of measurable data can be built into the EMR for report generation.

If the team wanted to look at the number of times vital signs were not documented as dictated per Policy & Procedure. This data can be built into the system and reports run daily, weekly, or monthly. The same thing can be built to monitor for overdue or omitted medications. This can be further expanded to identify which team member is involved and to check for trends. Data may also be collected to support EBM. For example, tracking the effectiveness of two different antibiotic treatment regimens of a selected disease process may be used to support a change in the disease treatment (e. . antibiotic A showed improvement in five days where as antibiotic B showed improvement in ten days. ) Here again the possibilities seem endless. Think of the time savings for all the key people that would be required to look through endless paper medical records for this type of data collection in the paper medical record. So how does the EMR come to fruition? It takes a large team of various specialties and specialists to develop the EMR. It starts with the Healthcare system researching and then purchasing the best system to fit the company’s needs and requirements.

Once purchased, the owner of the software will deploy a team of specialists that will assist the Healthcare systems team to design and develop the contents and flow of the EMR. The team includes senior management which will assist in the purchase and be the governing authority of the proposed Introduction to the Electronic Medical Record (EMR) work flow before implementation. There are many subdivided teams. Nursing will have Subject Material Experts (SME) that will be the voice to assist in the flow, wordage, and design of the nursing components of the EMR. The SME’s will be from every department of nursing.

From this group will be the Super User. The Super User will act as the cheerleader for the project development and will be the main source for assisting with the Go Live of the EMR. The Information Technology (IT) will be a multi-tiered group ranging from System Support Analyst or the front line of communication, the Computer Programmers and System Analyst or the builders and troubleshooters, to the Project Managers or the supervisors of the IT team. Nursing will also have the Clinical Informatics Application Analyst who will be the voice between nursing and the technical side of issues, concerns, and development.

The End User which is the front lines of nursing and everyone that will be using the system for documentation. And last but not least will be the Educators that will teach the system to the entire team. This is a rather large of individuals working as the voice of the EMR development and implementation. In conclusion, change will be rough at times but change is necessary for progression. Be positive and listen to the teams and the tips that are offered. Assist each other as support with the continued learning and development of the EMR. The Technology age is here and we should all reap the benefits of this endeavor.

Remember how Florence Nightingale was the frontier to nursing as we know it. Well each of you deserves a pat on the back as you are the pioneers that have lead nursing into the technology phase of the Electronic Medical Record. You too are a part of nursing history. References HIMSS. (n. d. ) EHR Electronic Health Record. Retrieved from http://www. himss. org/asp/topics_ehr. asp James, R. (n. d. ) What is HIPPA? Retrieved from http://www. dhmh. state. md. us/hipaa/whatishipaa. html Milne, M. (2006, March 6). HIPAA in a "Nutshell" - Guidelines for EMR and Paper Medical Records Compliance.

Retrieved from http://ezinearticles. com/? HIPAA-in-a-Nutshell---Guidelines-for-EMR-and-Paper- Medical-Records-Compliance&id=156737 Ten open ended questions. 1. When the EMR is first implemented on your unit, how can you assure the patient that you are competent in your profession? You will explain that you are a seasoned nurse and an expert in the nursing field. Today our facility is introducing the new EMR which will benefit you in the future. This will take a little more time for me to learn and I do not want you to feel like you are being ignored. I may have to ask you a lot of questions as I go through each section.

Please feel free to ask me any questions or concerns that you may have. Our goal is your comfort and safety though the high quality of care. 2. On the day of Go-Live, how can your unit best assist you in providing support as you learn this new technology? My unit manager should over staff initially as we learn the new system. I can foresee the nurse being so buried in the computer that the delivery of care might be too slow initially. Having the extra staff will decrease the patient load and allow extra hands to assist with the delivery of care. 3. As you learn the new system there will be some anticipated frustration.

How can you divert this frustration so that your patient doesn’t sense that something is wrong? We will need to have the Super-User and Analyst available to assist us as problems or concerns occur. It is imperative that the bed side nurse remain positive an up beat as we learn. I suggest maybe huddles through out the day away from the bed side to discuss our concerns. We don’t want the patient to feel uncomfortable. 4. Your patient asks you why it is important to have the computer charting. Briefly tell me what you might say and why? The EMR is being implemented throughout the area as well as world wide.

As you record develops, we will only need to verify some of your past medical history, allergies, medications, etc. These types of data will flow from one visit to another making you care easier as the data is readily available. No more waiting for old charts to arrive and thumbing through page after page of data to look for pertinent information. 5. How do you perceive future benefits of an interoperable EMR? It will be possible in the future as the EMR progresses, that your hospital record, physician office record, out patient records, and pharmacy to communicate with each other.

By doing so, some potential errors may be thwarted. For instance, maybe you are not able to recall all of your home medications and your consulting physician decides you need a new blood pressure medication. If the records could speak to each other then this physician would be able to see that you were already prescribed an antihypertensive medication or the pharmacy might catch the possible error. 6. Futuristically, let’s say you take a dream vacation to a foreign country. While on your visit you become ill and collapse unconsciously.

How can the interoperable EMR potentially be a benefit in this case? If the system develops into a world wide communication link, then with limited data perhaps the hospital in the foreign country would be able to access and utilize my EMR to provide answers in how to deliver the best possible care for me. So if I went in with a suspected ruptured appendix, by accessing my EMR surgical history it would be noted that I have had an appendectomy ten years prior so the focus could be directed at another possible cause. 7.

Your patient states to you that she hates the computer and that it is the devils advocate. She is tearful and appears anxious. How might you handle this as you are in the middle of documenting in the EMR? You should stop what you are doing and maybe sit beside the patient and gently hold her hand and ask what seems to be troubling her? She might say she feels the nurses spend more time touching the computer and no time touching her, as you just did, and that we come across as cold and not caring. We need to realize that patient interaction is still paramount to the overall delivery of care.

Take time to interact with the patient. Then step back and document; perhaps explaining what you are documenting and why it is important to her care. 8. What do you anticipate will be your plan of action when the computer system is down? What will be your back up plan? If the computer is down for a set amount of time, as determined by the hospitals administration, then the paper chart will be utilized. If the downtime is for an extended period of time, then this data would be scanned into the EMR as soon as possible after the computer system is back on line.

If the duration was short, say an hour or so, then this data should be manually documented back into the EMR with the assessment time documented. 9. How do you anticipate computer physician order entry being a benefit? For one legibility! No more trying to decode what you think may have been written. It will be clear and concise. Also the physician may be able to look at documentation form somewhere other than the patients unit and decide orders need to be given. He can simply do computer order entry and a task will appear for new orders.

If the order is anything other than routine, a call should be placed to alert the nurse of the priority. 10. What do see as a benefit to Quality Improvement by the institution of the EMR on a unit basis? We will be able to track data at a faster and higher accuracy a opposed to thumbing through paper record after record searching for data collection. The data collected can be as concise as to a particular nurse or a specific health issue. The data collected helps to support EBM change.

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